GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
RRP Podiatry
02
These are codes to restrict recipient to specific
podiatric providers.
RRP Dental
03
These are codes to restrict recipient to specific
dental providers.
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
YES
(See notes)
YES
(See notes)
RRP Durable Medical Equipment
04
These are codes to restrict recipient to specific
durable medical equipment providers.
RRP Pharmacy
05
06
08
09
10
11
These are codes to restrict recipient to specific
pharmacy providers.
RRP Physician
These are codes to restrict recipient to specific
physicians.
RRP Clinic
These are codes to restrict recipient to specific
clinics.
RRP In-Patient Hospital
These are codes to restrict recipient to specific
hospitals for inpatient services.
RRP Dental Clinic
These are codes to restrict recipient to specific
dental clinics.
RRP Physician Group
These are codes to restrict recipient to specific
physician groups.
RRP Physician Assistant/Nurse Practitioner
12
These are codes to restrict recipient to specific
PA/NP providers.
YES
(See notes)
YES
(See notes)
YES
(See notes)
YES
(See notes)
Individuals can be in a Restricted Recipient Program (RRP) and enrolled in Health Home, but the Care
Manager should work with the recipient and contact their Managed Care Plan, if applicable, to ensure
compliance with any restrictions.
YES
(See notes)
YES
(See notes)
YES
(See notes)
YES
(See notes)
RRP Alternative Pharmacy
13
5/9/2017
These are codes to restrict recipient to specific
alternative pharmacy providers.
YES
(See notes)
Page 1
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
Enrollee in Special Needs MC Plan (HIV SNP)
20
This code is used to identify enrollees in Special
Needs Plans.
YES
(See notes)
Like mainstream plans, recipients can be members of HIV SNP and enrolled in a Health Home program.
Enrollee in Special Needs MC Plan (HIV SNP)
21
This code is used to identify enrollees in Special
Needs Plans.
YES
(See notes)
OMH Children's Waiver
23
This code is used to identify recipients in the
OMH Home & Community Based Services
(HCBS) waiver for seriously emotionally
disturbed (SED) children.
NO
(See notes)
Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver,
but cannot be in both as each provides individual care management services. Care managers should
work with individuals to determine which service best meets their needs.
OPWDD - Sub-Chapter A Exception
NO
25
This code is for individuals receiving OPWDD for
a limited period of time with no local shares.
LTHHCP - Long Term Home Health Care
Program (Lombardi Waiver)
30
35
Code used for individuals authorized for long
term care services who are eligible for nursing
home level of care and are residing in the
community. Services provided through a
certified LTHHCP provider.
Case Management Program; Medicaid Service
Coordination/Case Management Program
(Medicaid OMH, COBRA, AI TCM, OPWDD)
Comprehensive case management program.
5/9/2017
NO
(See notes)
Individuals receiving services through this waiver can either be enrolled in a Health Home or in the
waiver, but cannot be in both as each provides care management services. Care managers should work
with individuals to determine which service best meets their needs.
YES
(See notes)
Children receiving OMH TCM services are being transitioned and adults receiving HIV COBRA and OMH
TCM care management have transitioned into Health Homes. Individuals receiving OPWDD and EI TCM
services will transition to Health Home enrollment at a later date. First Time Mothers/Newborns will
not transition.
Page 2
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
NO
(See notes)
Individuals receiving services through this waiver can either be enrolled in a Health Home or in the
waiver, but cannot be in both as each provides care management services. Care managers should work
with individuals to determine which service best meets their needs.
YES
(See notes)
The care managers must work within the individuals established UT. Limitations on services may apply.
NO
(See notes)
At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver
participants wish to receive care management through a Health Home they must dis-enroll from the
waiver. Health Home care managers and OPWDD Medicaid Service Coordinator (MSC) managers should
work with individuals to determine whether the waiver or Health Homes can best meet their needs.
Utilization Threshold Exempt
38
Recipient is a resident of an ICF-DD Facility.
Aid Continuing
39
Recipient is subject to Utilization Threshold (UT)
and exempt from copay.
HCBS at Home Non-Intensive Residential
Habilitation
44
Recipient is in a HCBS Non-Intensive AHRH to
better serve consumers in their own homes and
reduce demand for more costly residential
placement.
HCBS at Home Intensive Residential
Habilitation
45
Recipient is in a HCBS IBS to better serve
consumers in their own homes and reduce
demand for more costly residential placement.
OPWDD Home & Community Based Services
Waiver - HCB (Pure Waiver)
46
NO
(See notes)
At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver
participants wish to receive care management through a Health Home they must dis-enroll from the
waiver. Health Home care managers and OPWDD Medicaid Service Coordinator (MSC) managers should
work with individuals to determine whether the waiver or Health Homes can best meet their needs.
NO
(See notes)
Identifies a recipient in home & community
based services waiver program (HCBS).
5/9/2017
Page 3
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
OPWDD HCBS Community Habilitation Phase 2
47
Identifies a recipient in home & community
based services waiver supervised CR or
supervised IRA.
OPWDD HCBS Supportive IRAs and CRs
48
Identifies a recipient in home & community
based services waiver supportive IRA & CR.
NO
(See notes)
NO
(See notes)
At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver
participants wish to receive care management through a Health Home they must dis-enroll from the
waiver. Health Home care managers and OPWDD Medicaid Service Coordinator (MSC) managers should
work with individuals to determine whether the waiver or Health Homes can best meet their needs.
OPWDD HCBS Supervised IRA
49
Identifies a recipient in home & community
based services waiver supervised IRA & CR.
NO
(See notes)
MCC Pharmacy
55
An HR recipient enrolled in the MCCP and
receiving pharmacy services from the primary
pharmacy.
YES
Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but
the care manager should work with the recipient and contact their Managed Care Plan to ensure
compliance with any restrictions.
YES
Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but
the care manager should work with the recipient and contact their Managed Care Plan to ensure
compliance with any restrictions.
YES
(See notes)
Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but
the care manager should work with the recipient and contact their Managed Care Plan to ensure
compliance with any restrictions.
MCC Physician
56
An HR recipient enrolled in the MCCP and
assigned to a primary physician or a preferred
provider. Non-emergent transportation must be
ordered by a primary provider only. Ancillary
services (pharmacy, DME & lab) must be
ordered by primary or referred provider.
MCC Clinic
58
5/9/2017
An HR recipient enrolled in the MCCP and
assigned to a primary clinic where s/he must
receive care or be referred for care. Ancillary
services (pharmacy, DME & lab) must be
ordered by primary only.
Page 4
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
YES
(See notes)
Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but
the care manager should work with the recipient and contact their Managed Care Plan to ensure
compliance with any restrictions.
NO
(See notes)
Individuals receiving services through this waiver can either be enrolled in a Health Home or in the
waiver, but cannot be in both as each provides care management services. Care managers should work
with individuals to determine which service best meets their needs.
MCC Hospital
59
A recipient enrolled in the MCCP and assigned
to a primary inpatient provider where s/he must
receive care.
Nursing Home Transition and Diversion Waiver
60
Recipient enrolled in Nursing Home Transition &
Nursing Home Diversion waiver
Care at Home (CAH) I (Administered by DOH)
62
The Medicaid-waiver CAH I program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
NO
(See notes)
Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver,
but cannot be in both as each provides care management services. Care managers should work with
individuals to determine which service best meets their needs.
Care at Home (CAH) II (Administered by DOH)
63
The Medicaid-waiver CAH II program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
NO
(See notes)
Care at Home (CAH) III (OPWDD)
64
5/9/2017
The Medicaid-waiver CAH III program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
NO
(See notes)
Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver,
but cannot be in both as each provides care management services. Care managers should work with
individuals to determine which service best meets their needs.
Page 5
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
NO
(See notes)
Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver,
but cannot be in both as each provides care management services. Care managers should work with
individuals to determine which service best meets their needs.
NO
(See notes)
Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver,
but cannot be in both as each provides care management services. Care managers should work with
individuals to determine which service best meets their needs.
Care at Home (CAH) IV (OPWDD)
65
The Medicaid-waiver CAH IV program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
Care at Home (CAH) VI (OPWDD)
67
The Medicaid-waiver CAH IV program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
Bridges to Health (B2H) Seriously Emotionally
Disturbed (SED)
72
Bridges to Health (B2H) Waiver services are
tailored to meet the child's specific, presenting
health care needs, and are not available through
other programs these children attend.
NO
(See notes)
Bridges to Health (B2H) Developmentally
Disabled
73
Bridges to Health (B2H) Waiver services are
tailored to meet the child's specific, presenting
health care needs, and are not available through
other programs these children attend.
NO
(See notes)
Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver,
but cannot be in both as each provides care management services. Care managers should work with
individuals to determine which service best meets their needs.
Bridges to Health (B2H) Medically Fragile
(MedF)
74
5/9/2017
Bridges to Health (B2H) Waiver services are
tailored to meet the child's specific, presenting
health care needs, and are not available through
other programs these children attend.
NO
(See notes)
Page 6
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
LTC D/D Asset Protection
75
Recipients are those who receive resource
exemptions in the amount of LTC insurance
benefit dollars paid to date. The amount
determines the amount of resources
disregarded in the Medicaid Budget Logic (MBL)
budget.
YES
LTC Total Asset Protection
76
Recipients are those who have complete
disregard of resources in Medicaid Budget Logic
(MBL).
YES
LTC Insurance-Non-Partnership
77
YES
Recipients have LTC insurance but not through
the Partnership for LTC.
Traumatic Brain Injury (TBI)
81
HCBS/TBI waiver services include: service
coordination, independent living skills training
and development (ILST), structured day program
services, substance abuse program services,
positive behavioral interventions and support
services (PBIS), community integration
counseling (CIC), home and community support
services (HCSS), environmental modifications
(emods), respite services, assistive technology
(AT), waiver transportation, and community
transitional services (CTS).
NO
(See notes)
Individuals receiving services through this waiver can either be enrolled in a Health Home or in the
waiver, but cannot be in both as each provides care management services. Care managers should work
with individuals to determine which service best meets their needs.
YES
(See notes)
Individuals can be in a Restricted Recipient Program (RRP) and enrolled in Health Home, but the Care
Managers should work with the individual and contact their Managed Care Plan to ensure compliance
with any restrictions.
Non-MMIS ID RRP Provider
82
5/9/2017
This code returns an eligible message
"Restricted recipient contact MC plan for
provider information"
Page 7
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
YES
(See notes)
The care manager should coordinate services within existing Fee-For-Services and Managed Care Plan
eligibility requirements.
Alcohol & Substance Abuse (ASA)
83
Recipient has been mandated to receive ASA
services FFS in some instances. The recipient
may also be in PCP where the plan is responsible
for payment of some services.
OMH Base/Community Rehab & Support (CRS)
with Clinical Treatment
84
YES
Recipient is enrolled in an outpatient rehab
program for mentally ill adults (OMH).
Recipients are exempt from UT.
OMH Base/Community Rehab & Support (CRS)
without Clinical Treatment
85
Recipient is enrolled in an outpatient rehab
program for mentally ill adults (OMH).
Recipients are exempt from UT.
YES
OMH Intensive Rehab & Ongoing Rehab
Services (IR/OR)
86
Recipient is enrolled in an outpatient rehab
program for mentally ill adults (OMH).
Recipients are exempt from UT.
YES
Money Follows the Person
89
YES
Managed Care Excluded
90
Recipient is excluded from mandated managed
care auto assignment of a plan
YES
Managed Care Exempt
91
5/9/2017
Recipient is exempt from managed care
enrollment
YES
Page 8
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
DOH/ Managed Care Exempt
92
Recipient is exempt from managed care
enrollment
YES
Managed LTC
93
Recipients are marked who are required to
enroll in a managed LTC program
YES
(See notes)
Individuals can be in both a Health Home and a MLTC plan. The Health Home and MLTC plan must have
an administrative services agreement outlining their respective responsibilities.
OMH Exempt
94
Recipient exempt from managed care
enrollment
YES
OPWDD Waivered Services Look-Alikes
95
96
Recipient exempt from managed care
enrollment
Seriously & Persistently Mentally Ill Adults
(SPMI) & Seriously Emotionally Disturbed
Children (SED)
Recipient exempt from managed care
enrollment
A1
Health Home Program - Care Management
Agency
Member is assigned, in outreach, or enrolled
with a Care Management Agency
YES
(See notes)
YES
(See notes)
Care Managers must check with OPWDD to ensure an individual is not receiving Care Management
from OPWDD before they can be outreached or enrolled in the Health Home Program. The following
steps MUST be taken to ensure there is not duplication of services:
• Step 1 - Enter Member's Name, Date of Birth, and CIN number in an excel file.
• Step 2 - Encrypt with password the excel file.
• Step 3 - Send excel file with subject line "RRE Code 95 Check" to OPWDD's BML at:
[email protected]
• Step 4 - Send the password to the same BML with the same subject line.
Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver,
but cannot be in both as each provides care management services. Care managers should work with
individuals to determine which service best meets their needs.
YES
Tentative date of release is March 2017.
YES
Tentative date of release is March 2017.
Health Home Program - Health Home
A2
Member is assigned, in outreach, or enrolled
with a Health Home
Assisted Living
AL
5/9/2017
System generated based on claims for assisted
living.
NO
Page 9
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
B7
RE CODE DESCRIPTION
Non EP BHP Aliessa
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
YES
Copay Exempt (Hospice)
C1
YES
Community First Choice Option
CO
NO
Community First Choice Option OPWDD
CF
NO
Transgender Male to Female
G1
YES
Transgender Female to Male
G2
YES
HARP Enrolled without HCBS Eligibility
H1
YES
HARP Enrolled with Tier 1 HCBS Eligibility
H2
YES
HARP Enrolled with Tier 2 HCBS Eligibility
H3
YES
HIV SNP HARP Eligible without HCBS Eligibility
H4
H5
5/9/2017
YES
HIV SNP HARP Eligible with Tier 1 HCBS
Eligibility
YES
Page 10
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
H6
H7
H8
H9
I1
I2
I3
I4
M1
N1
N2
5/9/2017
RE CODE DESCRIPTION
HIV SNP HARP Eligible with Tier 2 HCBS
Eligibility
Opted out of HARP
State-Identified for HARP Assessment
HARP Eligible- Pending Enrollment
OPWDD MC Class 1
OPWDD MC Class 2
OPWDD MC Class 3
OPWDD MC Willowbrook
MAGI Remains in WMS
Regular SNF Rate - MC Enrollee
SNF AIDS - MC Enrollee
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
YES
YES
YES
YES
NO
NO
NO
NO
YES
NO
NO
Page 11
GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE
RE CODE DESCRIPTION
COMPATIBLE WITH ADULT
HEALTH HOME SERVICES
POLICY NOTES
SNF Neuro-Behavioral - MC Enrollee
N3
NO
SNF Traumatic Brain Injury - MC Enrollee
N4
NO
SNF Ventilator Dependent - MC Enrollee
N5
NO
Partial Cap 21+ Nursing Home Certifiable
N6
N7
NO
NH Budgeting Approved
NO
Transfer Penalty Period DHPCO
N8
N9
NH
S1
5/9/2017
NO
NH Resident Pending NH Eligibility
Determination
Nursing Home
System generated based on claims for nursing
home.
Surplus Client Not Eligible for Medicaid MC or
Medicaid Advantage (NYC ONLY)
NO
NO
YES
(See Note)
Care manager should work with the individual to maintain their Medicaid eligibility.
Page 12
CHANGE LOG
CODE
CODE DESCRIPTION
WHAT CHANGED
OPWDD Waivered Services Look-Alikes
95
The Health Home Compatibility Changed from No to Yes with stipulations. Please see above.
Recipient exempt from managed care
enrollment
Health Home Program - Care Management
Agency
A1
A2
AL
B7
C1
G1
G2
TR
Member is assigned, in outreach, or enrolled
with a Care Management Agency
Health Home Program - Health Home
Member is assigned, in outreach, or enrolled
with a Health Home
Assisted Living
System generated based on claims for assisted
living.
Non EP BHP Aliessa
Copay Exempt (Hospice)
Transgender Male to Female
Transgender Female to Male
Transgender Individual
Added
Added
Added
Added
Added
Added
Added
Deleted as more specific codes were added. Please see G1 and G2.
Updated 1/25/2017
5/9/2017
Page 13
CHANGE LOG
CODE
23
35
CODE DESCRIPTION
OMH Children's Waiver
This code is used to identify recipients in the
OMH Home & Community Based Services
(HCBS) waiver for seriously emotionally
disturbed (SED) children.
Case Management Program; Medicaid Service
Coordination/Case Management Program
WHAT CHANGED
Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Changed policy notes to account for adults completion of transition and children transitioning into Health Homes.
Comprehensive case management program.
Care at Home (CAH) I (Administered by DOH)
62
The Medicaid-waiver CAH I program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Care at Home (CAH) II (Administered by DOH)
63
The Medicaid-waiver CAH II program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Care at Home (CAH) III (OPWDD)
64
The Medicaid-waiver CAH III program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Care at Home (CAH) IV (OPWDD)
65
5/9/2017
The Medicaid-waiver CAH IV program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Page 14
CHANGE LOG
CODE
CODE DESCRIPTION
WHAT CHANGED
Care at Home (CAH) VI (OPWDD)
67
The Medicaid-waiver CAH IV program provides
community-based services to physically disabled
children who require hospital or skilled nursing
home level of care, and allows the child to be at
home instead of in an institutional setting.
Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Bridges to Health (B2H) Seriously Emotionally
Disturbed (SED)
72
Bridges to Health (B2H) Waiver services are
tailored to meet the child's specific, presenting
health care needs, and are not available through
other programs these children attend.
Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Bridges to Health (B2H) Developmentally
Disabled
73
Bridges to Health (B2H) Waiver services are
tailored to meet the child's specific, presenting
health care needs, and are not available through
other programs these children attend.
Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Bridges to Health (B2H) Medically Fragile
(MedF)
74
92
CO
CF
I1
I2
I3
5/9/2017
Bridges to Health (B2H) Waiver services are
tailored to meet the child's specific, presenting
health care needs, and are not available through
other programs these children attend.
DOH/ Managed Care Exempt
Recipient is exempt from managed care
enrollment
Community First Choice Option
Community First Choice Option OPWDD
OPWDD MC Class 1
OPWDD MC Class 2
OPWDD MC Class 3
Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Added
Added
Added
Added
Added
Added
Page 15
CHANGE LOG
CODE
I4
M1
N8
N9
CODE DESCRIPTION
WHAT CHANGED
OPWDD MC Willowbrook
Added
MAGI Remains in WMS
Added
Transfer Penalty Period DHPCO
Added
NH Resident Pending NH Eligibility
Determination
Added
Updated
2/21/2017
CHANGE LOG
CODE
95
CODE DESCRIPTION
OPWDD Waivered Services Look-Alikes
Recipient exempt from managed care
enrollment
WHAT CHANGED
DELETED: To find a Developmental Disability Regional Office copy and paste the following link in your web browser:
https://opwdd.ny.gov/sites/default/files/documents/OPWDD-DDRO-Eligibilty-Coordinators.pdf
ADDED: new instructions for inquiries.
Updated
5/9/17
5/9/2017
Page 16